2025 Provider Membership Renewal Form

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Thank you for your commitment to the human services sector in Massachusetts. As we enter our 50th year - we reflect on our achievements together. We hope that you will be part of the next 50 years and encourage you to renew your Providers' Council membership TODAY for January 2025 thru December 2025.

Provider Member Organization:
Please note: Your organization may be found under "T" if your agency's name starts with "The".

Did your organization's mailing/billing address change in 2024?

YesNo

Please ensure the following information is up-to-date:

Address

Suite/Building #

City

State

Zip Code

Agency Phone Number

Membership Renewal Contact

Who should we reach out to at your organization in regards to membership?

First Name

Last Name

Job Title

President / CEO / Executive Leader

First Name

Last Name

Job Title

Financial Leader / CFO

First Name

Last Name

Job Title

HR Director / HR Leader

First Name

Last Name

Job Title

Public Policy Director

First Name

Last Name

Job Title

Communications Director

First Name

Last Name

Job Title

Learning / Training Director

First Name

Last Name

Job Title

Approximate number of employees:

Full Time:

Part Time:

Volunteer:

Primary Funding Agency/Source (ex. DDS)

Other Funding Source:

Annual Revenue (ex. $2,050,100 from line 12 of your most recent 990):
Please attach a copy of the first page of the 990.

First Page of your most recent 990

Additional Financial Statements

Annual Revenue Range (based off line 12 of most recent 990).
This will be verified upon receipt of 990 information and payment received. We will reach out if there is a discrepancy.

2025 Membership Dues:

How would you like to pay your annual 2025 Provider membership dues?

Total Due for Provider Member Renewal

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Contact Information

2025 Provider Membership Renewal Form

Provider Member Benefits